monica bharel md, mph commissioner of public health ... · 3/22/2019 · january 2015. powerpoint...
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Commonwealth of Massachusetts
Monica Bharel MD, MPH Commissioner of Public Health
January 12, 2017
Draft for Policy ng Purposes Only
Massachusetts DPH by the numbers
History dates back to 1799
8 Bureaus
6 Offices
More than 15 sites in
Massachusetts
~$1 billion budget
~3000 Employees
The Range of DPH
Prevention and Wellness – Health Access – Nutrition – Perinatal and Early Childhood – Adult Treatment – Data Analytics and Support – Housing and
Homelessness – Violence and Injury Prevention – Office of Statistics and Evaluation – Childhood Lead Poisoning Prevention – Community Sanitation – Drug Control – Occupational Health Surveillance – PWTF – SANE Program – Interagency Initiatives – Planning and Development – Prevention – Problem Gaming – Quality Assurance and Licensing – Youth and Young Adults – Early
Intervention – Children and Youth with Special Needs – Epidemiology Program – Immunization Program – Global Populations and Infectious Disease Prevention – STI Prevention – HIV/AIDS – Integrated Surveillance and Informatics Services – Clinical Microbiology Lab – Chemical Threat, Environment and Chemistry Lab – Childhood Lead Screening – Environmental
Microbiology and Molecular Foodborne Lab – STD/HIV Laboratories – Biological Threat Response Lab – Central Services and Informatics – Quality Assurance – Safety and Training – Health Care Certification and Licensure – Health Professional Licensure – Office of Emergency Medical Services – DoN – Medical Use of Marijuana – Shattuck Hospital – Mass Hospital School –
Tewksbury Hospital – Western MA Hospital – State Office of Pharmacy Services – Office of Local and Regional Health – Office of Health Equity – Accreditation and Performance Management – ODMOA – OPEM – HR and Diversity – Office of General Counsel – Office of CFO – Commissioner’s Office
Massachusetts Department of Public Health
Massachusetts DPH will be a national leader
in innovative, outcomes-focused public health
based on a data-driven approach, with a
focus on quality public health and
health care services and an
emphasis on the social determinants
and eradication of health disparities.
VISION Optimal health and well-being for all people in
Massachusetts, supported by a strong public health infrastructure and healthcare delivery.
MISSION
The mission of the Massachusetts Department of Public Health (DPH) is to prevent illness, injury, and premature death; to ensure access to high quality public health and health care services; and to promote wellness and health
equity for all people in the Commonwealth.
DISPARITIES
We consistently recognize and strive to eliminate health
disparities amongst populations in Massachusetts,
wherever they may exist.
DETERMINANTS
We focus on the social determinants of health - the conditions in which people
are born, grow, live, work and age, which contribute to
health inequities.
DATA We provide relevant, timely
access to data for DPH, researchers, press and the
general public in an effective manner in order to target
disparities and impact outcomes.
INCLUSIVENESS AND COLLABORATION
EVERYDAY EXCELLENCE
PASSION AND INNOVATION
Social Determinants of Health
Social determinants of health refer to conditions of society that reflect root causes of community and individual health and well-being.
• There may be significant differences in the distribution of these social and environmental resources, with a significant association between these resources and health outcomes.
• These determinants drive health inequities
Advancing Community Public Health Systems in the 21st
Century. National Association of County and City Health
Officials, 2001.
Individual resources
Education, occupation, income, wealth
Neighborhood resources
Housing, food choices, public safety, transportation, parks and recreation, political clout
Hazards and toxic exposures
Pesticides, lead, reservoirs of infection
Opportunity structures
Schools, jobs, justice
Determinants of Health
CDC: Social Determinants of Health and Social Determinants of Equity, the Impacts of Racism on the Health of our Nation
Social determinants
of health (contexts)
Individual
behaviors
CDC’s Health Impact Pyramid AJPH April 2010
Counseling and
education
Clinical interventions
Long-lasting protective interventions
Changing the context to make individuals’ default decisions healthy
Socioeconomic factors
Largest impact
Smallest impact
Eat healthy, be physically active
Rx for high blood pressure,
high cholesterol, diabetes
Immunizations, brief
interventions
Fluoridation, no trans fat,
smoke-free laws
Poverty, education, housing,
inequality
Total Annual Expenditures by Expenditure Group for BHCHP Users
with Medicaid in 2010 A JPH 2012
25%
1.4%
25%
6.5%
25%
18.6%
15%
25.5%
10%
48.0%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Users (N=6,493) Expenditures ($149 million)
90 – 100% (650 users)
75 – 90% (974 users)
50 – 75% (1,623 users)
The gap in life expectancy between the richest 1% & poorest 1% of
individuals: 14.6 years
JAMA online April 10, 2016
U.S. Infant Mortality
Rate 2011
CDC Vital Statistics
Infant Mortality Rates in Massachusetts’ Largest Cities 2012
The opioid epidemic burden in Massachusetts
74% OF OPIOID DEATHS IN 2016 HAD THE PRESENCE OF FENTANYL
The opioid epidemic burden in Massachusetts
The opioid epidemic burden in Massachusetts
The opioid epidemic burden in Massachusetts
The opioid epidemic burden in Massachusetts
The rate of NAS is increasing significantly in Massachusetts
Sources:
1. Gupta M and Picarillo A. Neonatal abstinence syndrome (NAS): improvement efforts in Massachusetts. neoQIC. January 2015. PowerPoint presentation.
2. Patrick S, Davis M, Lehman C, Cooper W. Increasing incidence and geographic distribution of neonatal abstinence syndrome: Unites States 2009 to 2012. Journal of
Perinatology 2015; doi: 10.1038/jp.2015.36. [Epub ahead of print]
From 2004 to 2013 the Incidence of NAS increased from <3/1000 hospital births to >16/1000 hospital births per year
National average
3.4
5.8
MA rate of NAS was
triple the national average in 2009
Prevention Intervention Treatment Recovery
Governor Baker’s Opioid Working Group
Survey: reason for prescription painkiller misuse
Too easy to get painkillers from those whosave pills
Painkillers are prescribed too often or indoses that are bigger than necessary
Too easy to buy prescription painkillersillegally
47%
50%
58%
Source: Boston Globe and Harvard T.H. Chan School of Public Health, Prescription Painkiller Abuse: Attitudes among Adults in
Massachusetts and the United States
Preventing Prescription Drug Misuse: Screening, Evaluation, and Prevention
1. Evaluate a patient’s pain using age, gender, and culturally appropriate evidence-based methodologies.
2. Evaluate a patient’s risk for substance use disorders by utilizing age, gender, and culturally
appropriate evidence-based communication skills and assessment methodologies, supplemented with relevant available patient information, including but not limited to health records, family history, prescription dispensing records (e.g. the Prescription Drug Monitoring Program or “PMP”), drug urine screenings, and screenings for commonly co-occurring psychiatric disorders (especially depression, anxiety disorders, and PTSD).
3. Identify and describe potential pharmacological and non-pharmacological treatment
options including opioid and non-opioid pharmacological treatments for acute and chronic pain management, along with patient communication and education regarding the risks and benefits associated with each of these available treatment options.
Medical Core Competencies: Primary Prevention Domain
Prevention Intervention Treatment Recovery
Governor Baker’s Opioid Working Group
MassPAT: The new PMP
Reversing an Overdose: Use of Naloxone
Prevention Intervention Treatment Recovery
Governor Baker’s Opioid Working Group
Adding hundreds of new treatment beds across the state; Beginning the transfer of women civilly committed under Section 35
at MCI Framingham to Taunton State Hospital; Reinforcing the requirement that all DPH licensed addiction
treatment programs must accept patients who are on methadone or buprenorphine medication;
Strengthening the state’s commitment to residential recovery programs through rate increases.
Issuance of Division of Insurance guidelines to commercial insurers on the implementation of the substance use disorder recovery law (Chapter 258) which requires insurers to cover the cost of medically necessary clinical stabilization services for up to 14 days without prior authorization;
Treatment and Recovery: General Progress To-Date
Substance Use, Treatment, Education and Prevention Law (STEP)
Ch. 52 of the Acts of 2016
• 7 day limit on a first time opioid prescription; allows for a
pharmacist partial fill • Patient voluntary non-opioid directive (12/16) • SBIRT must be implemented in schools by June 2018 • Amends the Civil Liberties law so that any person who
administers naloxone is not liable for injuries resulting from the injection
• Requires substance abuse evaluation in ED when present for an OD (7/16)
Chapter 55 – Data mapping
PDMP
APCD Spine
Death Records
BSAS Treatment
Toxicology
Summarized APCD
MATRIS (ambulance)
OCME Intake
Town/Zip Level Data
Summarized Casemix
Dept of Corrections
MA Sheriff’s Association
System Attributes
• Data encrypted in transit & at rest
• Limited data sets unlinked at rest
• Simplified structure using summarized data
• Linking and analytics “on the fly”
• No residual files after query completed
• Analysts can’t see data • Automatic cell suppression • Possible resolution to issues
related to 42 CFR part 2
Data Sources
DPH
CHIA (MassHealth)
EOPSS
Jails & Prisons
All Doors Opening
• Significant coordination within DPH
• Financial and technical support from MassIT’s Data Office
• CHIA takes on role as linking agent
• Coordination across agencies (legal & evaluation)
• Volunteer analytic support from academia and industry
Chapter 55 Data Structure
Births (NAS)
DRAFT - FOR POLICY DEVELOPMENT ONLY
* Note: Houses of Correction data was
unavailable at the time this report was
written. As such, assessment does not
reflect HOC inmate outcomes.
*
31
DRAFT - FOR POLICY DEVELOPMENT ONLY
32
Chapter 55: Key Finding
Patients treated with methadone and/or buprenorphine (Opioid Agonist Treatment or “OAT” that block the effect of opioids) following a non-fatal overdose were significantly less likely to die; however, very few patients (~5%) engage in OAT following a non-fatal overdose.
0
0.5
1
1.5
2
2.5
Engaged in OAT Not Engaged in OAT
Cu
mu
lati
ve In
cid
en
ce (
%)
Figure 2: Cumulative Incidence of Opioid-Related Death by OAT Status
DRAFT - FOR POLICY DEVELOPMENT ONLY
33
Chapter 55: Key Finding
The risk of opioid overdose death following incarceration is 56 times higher than for the general public.
869.4 opioid deaths / 100,000
15.4 opioid deaths/ 100,000
0
100
200
300
400
500
600
700
800
900
1000
Former Inmates All Others
Comparison of Opioid Death Rates Among Former Inmates to the Rest of State (2013 - 2014)
Monica Bharel, MD, MPH Commissioner of Public Health